Varicocele: Difference between revisions
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Urology4all (talk | contribs) Created page with "== Background == * '''Definition of a varicocele: abnormal dilation and tortuosity of the gonadal/internal spermatic veins within the pampiniform plexus''' == Epidemiology == * '''Found in ≈15% of the general population, 35% of men with primary infertility''', and 75-81% of men with secondary infertility ** '''Prevalence of clinically diagnosed varicoceles in adolescents (8-16%) similar to prevalence in adults (15%)''' ** Adolescent varicocele may contribute signifi..." |
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== Diagnosis and Evaluation == | == Diagnosis and Evaluation == | ||
* | * Vast majority of varicoceles in children and adolescents are identified incidentally | ||
* '''History and Physical Exam''' | * '''History and Physical Exam''' | ||
** '''Physical Exam''' | ** '''Physical Exam''' | ||
*** ''' | *** '''Examine the patient in both the supine and standing positions.''' '''The veins should decompress in the supine position; failure to do so, particularly on the right side, warrants evaluation (CT or sonogram) for an abdominal or pelvic mass.''' | ||
** '''Testicular consistency''' should be assessed; the affected testis may be soft. | *** '''Testicular consistency''' should be assessed; the affected testis may be soft. | ||
** '''Measurement of testicular volume''' is important because it may predicate surgical intervention | *** '''Measurement of testicular volume''' is important because it may predicate surgical intervention | ||
== Management == | == Management == |
Revision as of 11:30, 7 March 2023
Background
- Definition of a varicocele: abnormal dilation and tortuosity of the gonadal/internal spermatic veins within the pampiniform plexus
Epidemiology
- Found in ≈15% of the general population, 35% of men with primary infertility, and 75-81% of men with secondary infertility
- Prevalence of clinically diagnosed varicoceles in adolescents (8-16%) similar to prevalence in adults (15%)
- Adolescent varicocele may contribute significantly to the risk of subfertility in adulthood
Pathogenesis
- The primary factors are believed to be:
- Increased venous pressure in the left renal vein
- Valvular incompetence of the gonadal vein at its junction with the left renal vein
- Collateral venous anastomoses
- The “nutcracker phenomenon” (compression of the left renal vein between the aorta and superior mesenteric artery) may account for the varicocele in some boys
- A tall, thin body habitus (low BMI) is associated with varicoceles in adolescents and adults
- Solitary right varicoceles are rare. Should one be of abrupt onset, renal pathology such as tumour should be considered
Grading
- Grade 0 (subclinical): non-palpable and visualized only by colour-doppler US
- Grade 1: palpable only with Valsalva maneuver but not visible on physical exam
- Grade 2: easily palpable but not visible on physical exam
- Grade 3: easily visible on physical exam
Associated Pathologic Processes
- Can impair testicular growth and fertilty with a progressive and duration-dependent decline by interrupting counter-current heat exchange provided by pampinoform plexus, resulting in increased testicular temperature
- Testicular growth
- “Catch-up” growth, defined as normalization of left relative to right testicular size, occurs in 32-83% of patients after varicocele repair
- Significant discrepancy between left and right testicular size remains the primary indication for varicocele correction
- Fertility
- Reliable standards for semen quality based on Tanner stage or age do not exist
- Trends toward poorer sperm quality may be limited to a subset of affected males with varicocele
- Varicocle grade and postoperative testicular catch-up growth do not reliably predict ultimate semen quality
- Hormonal Function
- LH and FSH levels are not consistently different in the presence or absence of varicocele in adolescents
- Testicular growth
Diagnosis and Evaluation
- Vast majority of varicoceles in children and adolescents are identified incidentally
- History and Physical Exam
- Physical Exam
- Examine the patient in both the supine and standing positions. The veins should decompress in the supine position; failure to do so, particularly on the right side, warrants evaluation (CT or sonogram) for an abdominal or pelvic mass.
- Testicular consistency should be assessed; the affected testis may be soft.
- Measurement of testicular volume is important because it may predicate surgical intervention
- Physical Exam
Management
- Observation remains the approach of choice for the majority of adolescents with varicocele until a surgical indication is present
- Varicocelectomy
- Indications (4):
- Significant (≥20%) size discrepancy
- Bilateral testicular hypotrophy
- Abnormal semen analysis findings; most reliable in boys of Tanner stage 5 and/or at least 18 years of age
- Pain; a rare indication
- Potential benefits
- Halt the progressive duration-dependent decline in semen quality found in men with varicoceles.
- Repair of large varicoceles results in a significantly greater improvement in semen quality than repair of small varicoceles
- Microsurgical varicocelectomy results in return of sperm to the ejaculate in up to 50% of azoospermic men with palpable varicoceles
- A randomized controlled trial of surgery versus no surgery in infertile men with varicoceles revealed a pregnancy rate of 44% at 1 year in the surgery group versus 10% in the control group.
- See Risk Caculator for Predicting Changes in Semen Parameters in Infertile Men After Varicocele Repair
- Repair of large varicoceles results in a significantly greater improvement in semen quality than repair of small varicoceles
- Improve Leydig cell function, resulting in increased testosterone levels
- In infertile men with low serum testosterone levels, microsurgical varicocelectomy alone results in substantial improvement in serum testosterone levels
- Halt the progressive duration-dependent decline in semen quality found in men with varicoceles.
- The pampiniform plexus of veins forms from the gonadal/internal spermatic veins.
- These veins are ligated during varicocele ligation surgery.
- Deferential veins follow the vas deferens and empty into the internal iliac/hypogastric veins.
- These veins are spared during varicocele ligation surgery.
- Approaches (5)
- Radiographic
- Retroperitoneal
- Laparoscopic
- Conventional inguinal
- Microsurgical Inguinal and Subinguinal
- Indications (4):
- Radiographic
- Venographic placement of agents (3% sodium tetradecyl sulfate or polidocanol, with or without intravascular coils or balloons)
- Can be done in either a retrograde or antegrade fashion
- Advantages:
- Identify and classify the venous collateralization as possible routes of outflow and reflux
- Minimally invasive approach through a transfemoral venous puncture done under local anesthesia (with or without sedation)
- Disadvantages
- High incidence of varicocele recurrence
- Radiation exposure
- Short follow-up in available literature
- Retroperitoneal
- Involves incision at the level of the internal inguinal ring, splitting of the external and internal oblique muscles, and exposure of the gonadal/internal spermatic artery and vein retroperitoneally near the ureter.
- Still a commonly used method for the repair of varicocele, especially in children.
- Advantages:
- Involves ligation of the fewest number of veins
- This approach isolates the gonadal/internal spermatic veins proximally, near the point of drainage into the left renal vein. At this level, only 1-2 large veins are present, and in addition the testicular artery has not yet branched and is often distinctly separate from the internal spermatic veins.
- Despite the above statment, CW11 Table 25-5 suggests that the artery is not preserved with retroperitoneal approach
- This approach isolates the gonadal/internal spermatic veins proximally, near the point of drainage into the left renal vein. At this level, only 1-2 large veins are present, and in addition the testicular artery has not yet branched and is often distinctly separate from the internal spermatic veins.
- Involves ligation of the fewest number of veins
- Disadvantages:
- High incidence of varicocele recurrence and hydrocele formation
- Laparoscopic
- In essence a retroperitoneal approach
- Similar advantages and disadvantages to those of the open retroperitoneal approach
- High incidence of hydrocele formation
- Conventional inguinal
- Disadvantages:
- High incidence of hydrocele formation
- Artery not preserved
- If an inguinal approach is selected, the external oblique aponeurosis is cleaned and opened the length of the incision to the external inguinal ring in the direction of its fibers. A 3-0 absorbable suture placed at the apex of the external oblique incision facilitates later closure. The spermatic cord is grasped with a Babcock clamp and delivered through the wound. The ilioinguinal and genital branches of the genitofemoral nerve are carefully excluded from the cord, which is then surrounded with a large Penrose drain
- Disadvantages:
- Microsurgical Inguinal and Subinguinal
- Advantages
- Facilitates artery and lymphatic sparing
- Low rate of varicocele recurrence
- Low risk of hydrocele
- Disadvantages:
- May be time-consuming
- Requires microscopic surgical skills
- Indications for inguinal vs. subinguinal varicocelectomy (see CW11 Table 25-6)
- Subinguinal approach
- Currently the most popular approach
- Preferred in men with a history of any prior inguinal surgery
- Significantly more difficult than a high inguinal operation and should be used only by surgeons who perform the operation frequently
- Associated in rare cases with testicular atrophy (necrosis), which has not been reported for suprainguinal procedures
- Inguinal approach
- Used when simultaneous ipsilateral hernia repair is performed
- Subinguinal approach
- An inguinal or subinguinal approach allows access to cremesteric/external spermatic vein and even gubernacular veins
- At the completion of the microsurgical varicocelectomy, only the testicular arteries, cremasteric arteries, lymphatics, and vas deferens with its vessels remain (i.e. deferential artery and vein are intact)
- As long as at least one set of deferential veins remains intact, venous return will be adequate
- Advantages
- Scrotal
- Avoided because damage to the arterial supply of the testis frequently results in testicular atrophy and further impairment of spermatogenesis and fertility
- Radiographic
- Complications
- Failure (varicocele persistence or recurrence)
- Hydrocele formation after varicocelectomy is caused by lymphatic obstruction
- Injury or ligation of the testicular artery carries with it the risk of testicular atrophy and/or impaired spermatogenesis
- See Table 25-5 for techniques and complications of varicocelectomy
- UrologySchool.com Summary of Table
- High rates of varicocle recurrence: retroperitoneal and radiographic
- High rates of hydrocele: retroperitoneal, laparoscopic, and conventional inguinal
- Artery not preserved: retroperitoneal and conventional inguinal
- UrologySchool.com Summary of Table
- See Table 25-5 for techniques and complications of varicocelectomy
References
- Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 25
- Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 146